“Mailbag #5: with Dr. Sam Bender”

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, Sam Bender, welcome back to the podcast. It’s been a while since I’ve had you in the hot seat.

Dr. Bender: Yeah, I think it was at the beginning of the pandemic, so it must be close to three years.

Dr. Fox: Yeah, I think the bridge of your nose has finally healed.

Dr. Bender: A little bit. A little bit, yeah.

Dr. Fox: From your permanent mask scar. That was gruesome.

Dr. Bender: Yep, and I managed to help fund, you know, I think college funds for a lot of dermatologists on the Upper East Side of Manhattan.

Dr. Fox: Amazing. Well, we’re going to be doing a Mailbag podcast, and as I was telling you before, basically our listeners send in their questions from all over the world, all sorts of topics, and we address them. We’re going to hit them one at a time, so let’s start. And just so our listeners know, I did not prep Sam with the questions in advance. Unlike “Quiz Show,” he’s not cheating. This is really right on the spot. So you’re getting full, unfiltered Bender right now. Here we go.

Dr. Bender: Fire away.

Dr. Fox: So question number one is from Rachel, and her question is a short one, but a very good one. “Does having an abortion affect your fertility down the road?

Dr. Bender: Oh. If everything is uncomplicated, then the short answer is no, not a bit. Stopping a pregnancy, or finishing any pregnancy is a self-limited thing. Afterwards, everything should go back to your normal. It can take, you know, a cycle or two, or a month or two, to have your menstrual cycle go back to your normal, depending on how far the pregnancy was, and what method of pregnancy termination is picked. But an uncomplicated pregnancy termination should not affect future pregnancy.

Of the various different surgical procedures that can be employed to stop pregnancies at an early stage, like any surgical procedure, there are potential for complications. We go out of our way to safeguard against complications. For example, premedicating with an antibiotic before a surgical procedure is recommended. And going and having a procedure done by somebody skilled in the procedure is obviously in the best interest of a patient looking to stop a pregnancy.

With early pregnancies, we even have non-surgical techniques that have gained favor, and are even safer in many respects. Whenever a patient is having surgery, we counsel the patient in regards to potential complications of surgery, and interestingly, no matter what procedure we’re talking about, whether it’s a small procedure like dilatation and curettage to empty the uterine content, or brain surgery, or a cesarean section, the risks that we talk about are actually always the same three things. You’re talking about the potential for infection, for bleeding, for damage to whatever you operate on, whatever’s near it, and different procedures have obviously different risks. But in skilled hands, surgical termination of pregnancy should not affect future pregnancy. There are small risks of having infections, or damage to the uterus with some of these procedures, but there are various techniques that we employ to minimize these risks.

Dr. Fox: And it’s really not different from a natural miscarriage. Meaning the chance of having a complication from a miscarriage, you can get an infection. Again, it depends if you need a procedure or not for an incomplete miscarriage. But things like bleeding or scar tissue, I mean, anything can happen after any pregnancy. But I think the point is, these are very safe procedures, and the chance of a complication is very, very low, fortunately.

Dr. Bender: Absolutely correct. And when I talk about terminating a pregnancy, I’m not limiting my conversation to terminating an unwanted pregnancy.

Dr. Fox: Right.

Dr. Bender: But you know, we discuss stopping any pregnancy, whether it’s abnormal or not viable, versus a pregnancy that is viable, that is unwanted. The techniques and the surgical procedures are the same, and the risks are the same.

Dr. Fox: Right. Okay, great. Next question from Hannah. “Hi, I saw Dr. Fox’s episode on “The Toast…” And by the way, do you know what “The Toast” is, Sam?

Dr. Bender: I don’t.

Dr. Fox: Well, you’re not a millennial. “The Toast” is a very popular podcast, who I just interviewed one of the hosts, Jackie Oshry, who was a patient of ours, as you know. It’s not a secret, because she just came and talked about it on the podcast. But they have a very, very popular podcast that I’m sure many people you know know about it, but like you, I didn’t know about it either before.

All right, “So I saw Dr. Fox’s episode on “The Toast,” and learned about this podcast. The question I have that I can’t seem to get a straight answer is, are IUDs considered an abortifacient?” Meaning, do they cause abortion? “I’ve talked to a few different people, and done some research, and don’t seem to find a clear answer. I understand it is not something that can necessarily be tested ethically, so does that mean there’s no definitive answer, therefore you make a decision based on your comfort level? And then, to give context, I am pro-life and when my doctor discussed birth control options with me, it never came up, and I never knew to ask about how my morals played a factor in that decision. It wasn’t until a well-intentioned friend with similar convictions brought up the subject that I was open to this possibility.”

So how do IUDs prevent pregnancy? Do they prevent it, or do they end it?

Dr. Bender: Great question. And interestingly, a lot of the data about how IUDs work really wasn’t elucidated until fairly recently. There are two different types of IUDs that are available in this country. One is a hormonal IUD, that contains progesterone in some amount, and the progesterone IUDs have advantage that they actually improve menstrual cycle, as well as preventing pregnancy. They’re not a device that would cause a pregnancy to be terminated. In fact, the progesterone IUD is thought to work on multiple levels. The progesterone itself thins the lining of the uterus so that implantation of the embryo, if one were to be created, would not occur. It’s thought to prevent fertilization in most instances by affecting both the cervical mucus of the patient, as well as the transit time in the fallopian tube. And so it probably works on multiple levels, but the short answer is that it does not terminate a pregnancy. It likely prevents both fertilization, as well as implantation. And the combination is thought to provide what the companies cleverly call “nearly” 100% birth control.

Dr. Fox: Right.

Dr. Bender: It’s considered probably the top method of preventing pregnancy in terms of birth control. It’s right there next to abstinence.

Dr. Fox: Yeah.

Dr. Bender: The copper IUD is an IUD that in various forms has been utilized for birth control going back centuries. It’s actually got sort of an interesting history. But the copper IUD has been shown to prevent fertilization. It does not improve periods, it does not affect the lining of the uterus tremendously, it doesn’t affect when menstrual periods are going to occur, and it does not affect ovulation. What it does do is that it’s thought that the copper that’s wrapped around, literally, a T-shaped piece of plastic that’s placed inside of the uterus, that this copper carries with it a positive charge, and that the membrane of the sperm cell and the membrane of the egg cell do not interact because of these positively charged ions that are present in both the uterus and the fallopian tube as a result of placing the IUD.

Delving back into some of the bizarre history of the copper T IUD is that copper was long thought to be a magical thing that prevented pregnancy. And there are stories that go back to apparently Bedouins that had magical rocks that they would put inside the uterus of their camels before going across the desert so that the camel would not get pregnant. And they didn’t, obviously, at that period of time have any clue how this worked, and so they thought it was magic. You know, fast forwarding to 2023, you know, the Bedouins are no longer with us, and those camels are long gone, but they actually have the rocks, and they have tested them, and they contain copper. And so the history of the IUD goes way, way back.

Dr. Fox: Wow. But the short answer is no, they do not cause abortion?

Dr. Bender: No abortion. They do prevent…they’re both thought to prevent fertilization. The progesterone IUD has effect on preventing implantation. Interestingly enough, both types of IUD can be used as morning after kind of contraception as well, because essentially, you’re placing it before fertilization would have occurred.

Dr. Fox: Right, exactly. All right, cool. Good stuff. So Hannah, no worries. You’re good. An IUD should work.

All right, next question is from Sabina. “Hi, Dr. Fox. Just listened to your podcast with Jackie,” Sam, that’s also “The toast,” and I really enjoyed it, especially how informative and down to earth you were. It got me thinking, would you be able to speak on prolapse? Just had my first baby, I had natural physiological birth, and now three months postpartum, I’m noticing a minor prolapse. My GP said it’s a stage one. I’d be interested to know more how to get rid of it, as I’m not finding any helpful info online about it, and my doctor just said to get used to it.” Mm, yikes. “It would really be helpful to hear from you and/or your guests to speak on it.”

I’m definitely happy that you’re here, Sam. This is a gynecologic issue that is common, and you have a lot of expertise in it. So what would you say about… Let’s talk about prolapse in general, and then, like, what it is, what we’re talking about, and then prolapse specifically related to a recent pregnancy.

Dr. Bender: Okie dokie. So there are various different supports in terms of ligaments within the pelvis of how the uterus is supported, the bladder is supported, and there are different layers within the anatomy that help provide support for what we call the pelvic floor. There are a series of muscles that are present, and typically when we are discussing prolapse, we’re talking about a change in the normal architecture of the pelvis, that “things aren’t quite the way they used to be.” And some people use euphemisms as, you know, like my uterus has dropped, my cervix has dropped, the bladder has fallen, and all of these things are describing the normal support, or the pre-pregnancy support that existed in this area that, you know, prior to a pregnancy, labor or delivery.

Prolapse is described in various different ways, from, you know, different classes, to different ways of doing the physical exam that other gynecologists can look at your values, and get a sense of what has changed, what is lower, you know, in the pelvis than it used to be. There are a series of people in our field that specialize in the management of pelvic floor prolapse, and it’s got its own fellowship and its own discipline called urogynecology. And the urogynecologist specializes in evaluating patients for what type of prolapse they have, and tailoring treatment options depending on severity of symptoms that somebody has.

Although it may be true that the anatomy is going to be a little bit altered after even an uncomplicated pregnancy and natural delivery, it doesn’t necessarily mean that somebody is going to have abnormal symptoms related to this. It doesn’t mean that having sexual intercourse is going to be uncomfortable. It doesn’t mean that you’re not going to be able to hold your urine when you cough, sneeze, lift, and you know, get back to normal activities, or even strenuous exercise, but it means that for some patients, these changes can result in symptoms. In general, prolapse is sort of a big term that describes almost any kind of a change where the anatomy in the pelvis has been altered, where the cervix may be lower into the vagina than it used to be, where there may be bulging of the vaginal walls from either the bladder pushing down, or the rectum pushing up, and then what to do, you know, how to prevent, how to fix is exactly what the urogynecologist is all about.

The first questions I ask when a patient has had a baby is ascertaining whether or not there are other symptoms. Is there a discomfort? Is there an issue with urinary incontinence that has changed since delivery? And coupling symptoms with examination, you can figure out sort of what the next steps may be. There’s a natural healing time after having a baby where things will continue to improve without having major procedures performed, like additional surgeries. In the early period after having a baby, hormonal changes may contribute to a delay in some of the anatomic healing that could happen naturally. But there are also a subset of patients that have had significant change in their anatomy that leads to symptoms that the pelvic floor physical therapy, pelvic floor exercise, or even medication may not alleviate, and those patients may ultimately turn up being candidates for a surgical repair.

Dr. Fox: How do you decide when you see someone after delivery, because pretty much everyone after delivery, like you said, is going to have some anatomic differences compared to before, especially if it’s their first baby. How do you decide, when you see in typically six weeks or two months or whatever it is, whether you’re going to recommend anything, versus just watch and wait? Is it just based on other symptoms, or is it based on the severity, and your exam? Like, what is it that you use to make that decision?

Dr. Bender: Yeah, great question. Both is the real answer. The examination is key, but even before that, the conversation is important, you know? Open-ended questioning, you know, with introducing the topic, and asking what changes have you noticed is a simple starting point, and you get a good sense of what’s been going on since the delivery. There are obviously some stories where you’re going to be far more concerned, and do a deep dive or a bigger examination more rapidly. A patient that has had a very large baby, a very prolonged labor, a larger laceration than normal, you know, are the easy starting points. Those are the patients that you’re not going to wait six weeks or two months to begin to evaluate, you’re going to start much earlier.

Every patient needs to be evaluated at the postpartum visit, and every patient will benefit from some level of physical therapy, whether it’s learning to do a simple exercise that doesn’t require anything fancy, called the Kegel exercise, targeting the muscles that are supporting the pelvic floor, attempting to strengthen them. And I think that especially in a city like New York, there’s a lot of opportunity to find very good programs for pelvic floor physical therapy to help patients that are having difficulty figuring out how to do a Kegel, or having symptoms despite the fact that they’ve started these exercises.

But it starts with an expectation of how long this is supposed to last for. Temporarily, there is pelvic floor damage with any delivery, and thankfully, the body does a wonderful job in most instances for allowing recovery of this portion of the body. Sometimes it requires a longer recovery than other times. Sometimes, some patients require waiting until natural hormones have returned, you know, until they notice a more complete recovery. And some patients may not recover completely, depending on other factors that you can’t always predict, and those are the patients that you need to be able to identify and help target, you know, what therapies, other than simply waiting or trying, you know, pelvic floor PT may be of benefit.

Dr. Fox: Yeah, I mean, I don’t…I think for Sabina’s doctor who said, “Get used to it,” or that’s the message she got, I think that’s probably not great. I think that maybe there’s a component that can’t be fixed, and that’s just the consequence of having a baby. But I think until someone’s really given a real go at physical therapy, pelvic floor physical therapy, it’s hard to know if that’s the case. And I think, really, one of the ideas is that this is not something you really want to get surgery on until you’re done having kids, if you need surgery ever, right? Because [inaudible 00:32:38] do surgery, and then, if you have another kid, you pretty much…it’s very hard to deliver vaginally again because it’s going to potentially upset the surgery, and you have to do C-section.

So I would say it’s rare that people need surgery or get surgery before they’re done having kids, if ever.

Dr. Bender: Oh, agreed. No, I think saying get used to it is not the right answer. Get used to it, that sort of implies, you know, this is the way it has to be, and I have nothing to offer. My response would not be get used to it. My response would be, you know, a number of the things that you may be describing are completely normal. A lot of things will improve without doing anything whatsoever, other than giving it a little bit more time, and increasing that, you know, that recovery, and allowing the body to heal itself over a longer period of time. And you can be proactive, and say there are a number of small things that you can attempt on your own that may make things recover more rapidly.

Dr. Fox: Right.

Dr. Bender: And there are people out there that are very good, and programs that are very good for literally quantifying strength of various different muscles in your body, and allowing you to properly target how to exercise these muscles to be able to help in recovery.

Part of it, you know, may be just compensating. You know, part of it may not be quite ever the way it used to be, but most of it seems to not require surgical things, or super long recovery times. And like you said, it’s rare that after a single baby, anybody requires a surgical procedure. Most of the physicians that provide, you know, the type of surgery that, you know, that’s commonly done for extreme pelvic floor prolapse are procedures that are typically done once childbearing, you know, is complete, and many times are procedures that are best done in combination to even, you know, potentially removing the uterus, which obviously would not be ever done for anybody considering a future pregnancy.

Dr. Fox: Right. All right, excellent. Next question is from Leah. This is also going to be another Toaster. “New listener here. I am a Toaster, and found your podcast after your episode with Jackie, of “The Toast” Patreon. I absolutely love your podcast. I find this information SO interesting. I would love to hear your opinion on “natural” non-hormonal birth control methods, like tracking your ovulation cycle, and using male condoms during ovulation.” I would argue that’s not natural, but okay. “What would I need to know going into this to be able to do it effectively?”

Dr. Bender: Great. Great idea. We call it natural family planning. Some people used to call it the rhythm method, and it’s a very simple process. You know, you start with something really easy, which is, you know, can you get pregnant any time in your menstrual cycle? And the answer is no. In fact, it’s actually a fairly small window of time that one can conceive. If you can identify when your “fertile time” is, then this is the moment in time where either you abstain from having vaginal intercourse, or use some version of birth control.

Start with the basics. When a woman ovulates, that means releasing the egg, the egg can only be fertilized literally for the next couple of days, so about, you know, two days. In that 48-hour window, normal, living, healthy sperm need to be in the vicinity to fertilize the egg. On the man’s side, healthy men, their sperm live for roughly three days. And so when somebody is attempting to get pregnant, you identify the time that somebody is going to ovulate, and you time intercourse roughly every other day around the period of time you think you’re releasing an egg. And when we talk about natural family planning, you know, it’s the inverse.

Dr. Fox: Right.

Dr. Bender: You identify the time where you shouldn’t be having sex, if you’re hoping not to get pregnant.

And how do you know when you’re ovulating? That’s a good question, too. And so I start by asking a simple question, which is from the first day of one period to the first day of the next period, how long is your cycle? And many women have pretty consistent cycles. Twenty-eight days is the average cycle length for women, but some people it’s a little bit shorter, or a little bit longer, or you may have a small range. If a patient says to me, my periods are always 28 to 30 days apart, then it’s easy to have the next conversation of when can I conceive, or when should I be careful not to conceive. And an easy rule of thumb is if you look at the first day of your period, and you count back exactly 14 days, that’s when you made the egg. So patients that have a shorter cycle, 26 days, for example, may be releasing the egg on day 12. In patients that have a 30-day cycle may be releasing the egg, or ovulating on day 16.

And so if that’s the range, and the sperm live for three days, then if my patient said I have 26 to 30-day cycles, you would say, you know, your fertile window is potentially as early as day 9 of your cycle, or as late as day 19 of your cycle. That’s the time period that you employ other techniques, you know? And this caller was talking about making her partner use a condom, which is a barrier method of birth control, most definitely works. Not having sex at that time works. There are even studies that suggest, you know, that albeit, you know, potentially not foolproof, the man withdrawing before ejaculation has actually been researched, and if there isn’t an oops, you know, then it actually is reasonably good birth control as well.

Dr. Fox: Right. It’s not 100%, but it’s better than not doing it.

Dr. Bender: Yep.

Dr. Fox: Yeah.

Dr. Bender: It’s actually fairly close to the effectiveness of the condom.

Dr. Fox: Yeah, right, if you’re pretty… Because yeah, I think that doing, you know, what she referred to as natural birth control, or what you said, you know, used to call the rhythm method or whatever it is, again, I think that it is effective. It’s going to work. It requires some math. It’s not 100%, because sometimes your math is off, sometimes you don’t ovulate when you thought you were going to ovulate, your cycles could be off. And generally, they’re used for couples who they don’t want to conceive, but if they did, it wouldn’t be the end of the world, you know? It’s like that kind of situation. Whereas if someone is like, I absolutely, positively cannot conceive, generally we don’t recommend using those methods, because they’re not foolproof in a certain sense.

Dr. Bender: No. And if the issue is less about not using any birth control versus trying to avoid hormonal birth control, you know, then we’d talk about using non-hormonal, you know, nearly perfect types of birth control, like the copper IUD.

Dr. Fox: Right, like we talked about earlier. So that’s a good option.

All right, our last question, shifting gears a little bit more towards the labor side, we had two questions about the cervical lip. I did not think that would happen, and they happened within a week of each other, one was from Samantha, and one was from Jamie. I’m going to read Jamie’s first because it’s shorter. “What’s a cervical lip during labor? How is it treated, and when would there be an indication for a C-section if you have one? Update, I had a healthy baby boy. Loved your podcast through my pregnancy. All the information helped me feel informed and empowered during my labor, delivery, and now postpartum.” Samantha’s question is a little bit longer, but basically to paraphrase, she said, “I would love if you could talk about cervical lips on the podcast. I was first told by my labor and delivery nurse that I was 9 centimeters, only to be told by my midwife that actually, I was only 5 centimeters, but my cervix was swollen,” then we had a remedy in this, and ultimately she had a cervical lip.

What are we talking about, Sam? What is that? Because that sounds strange, the cervical lip.

Dr. Bender: Well, you know, I think it’s…you know, I don’t think it’s truly a medical term. I think it’s a term that’s been adopted to explain various different kinds of examinations that aren’t so clear. As a woman progresses in labor, we talk about cervical dilatation, and that’s how the cervix is opening. And when the cervix is completely open uniformly, the doctor refers to the patient as being 10 centimeters dilated. It’s not necessarily that she’s 10 centimeters dilated, it’s that on the examination, attempting to see how open the cervix is, you can no longer feel any portion of the cervix because the baby’s head has actually passed where the cervix is. And so at this point, we call it full dilatation, fully dilated, fully or 10 centimeters, and it all describes that on examination, you no longer can feel any portion of the cervix.

Not all babies descend into the pelvis exactly the same way. There are a series of what we call cardinal movements of the baby, as the baby descends in the pelvis, and rotates in a normal fashion so that the baby is literally looking down towards the floor as the baby progresses through the cervix, into the vaginal canal. There are many instances where the baby’s head is not coming down perfectly straight, it has not finished rotating to look down as the baby is navigating through the cervix, and the cervix is opening. And it’s not uncommon for the doctor to announce that, you know, that one portion of the cervix appears more open than another portion of the cervix in these instances.

And so as somebody gets past, or well-advanced into active labor at seven, eight, nine centimeters, it’s not uncommon in some instances to feel that there’s more cervix palpable at potentially the top of the vagina, and very little, if any, cervix palpable on examination at other portions around the baby’s head. And at this point, the terminology that’s commonly used is somebody will say that the cervix is at anterior lip, and what they’re really describing is that most of the cervix is completely open, but they can still feel a little bit of the cervix anteriorly at the top, as the baby has likely not finished rotating to look completely down. And the next examination, as the baby descends a little bit further in the birth canal, secondary to the contraction, the ongoing contractions, it’s not uncommon that the next examination somebody would be told that now their cervix is fully dilated, or at 10 centimeters.

There are instances where the baby is navigating through the pelvis, and instead of rotating to look down, the baby may actually be rotating to look up. And in this instance, if you’re dilating, and a portion of the cervix is identified as not completely opening, it may be a signal that this is a labor where the baby may arrest in the descent process in the pelvis. It literally may not be fitting. If this is the case, then after additional time, potentially hours, and more contractions, that portion of the cervix will feel as though it’s still there, and may actually feel as though it became what I believe she…

Dr. Fox: Swollen, yeah.

Dr. Bender: …she called swollen, or you know, essentially it’s becoming edematous. It’s gaining a little bit of fluid as the labor process or the descent process of the baby has stalled.

Dr. Fox: Right. I mean, basically it’s…you know, I think that this is probably an our fault thing in the messaging, and the cervical lip really just indicates your cervix is nearly fully dilated, but not quite there yet. And it’s not that the lip is holding the head back, it’s not that the lip is the problem, it may be a sign of a problem if it doesn’t go away. I mean, usually, like you said, you find it, and then X-hours later the head is rotated and passed through, and the patient’s fully dilated, or the cervix is fully dilated. But if the lip is staying there, and the head’s not coming through, it’s not that, like, the lip is obstructing it, it’s just that that’s a sign that the head’s not descending in the pelvis. And so we don’t consider it at all problematic to tell someone you have a cervical lip, an anterior lip, it just means that, hey, you’re almost there, and then hopefully soon you will be. It’s not much different from saying someone is nine or nine-and-a-half centimeters, it’s just maybe a little bit further than that.

Dr. Bender: Yeah. I would describe it as, you know, maybe not 10.

Dr. Fox: Yeah, 9.8. Yeah.

Dr. Bender: Yeah.

Dr. Fox: Yeah, almost, almost there. So yes, I think that maybe the messaging that both Samantha and Jamie got, that it was somehow a problem, it’s pretty common. If you check, people frequently enough, they’ll often be one. But again, usually it’s just going to go away as the head descends, and if it doesn’t, that’s a separate issue, but it’s not because of the lip, it’s just a sign of that.

Excellent. Sam, Mailbag, good job.

Dr. Bender: Hey, invite me back. This was fun.

Dr. Fox: [inaudible 00:32:38] All right, thanks everyone.

Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast, or any other topic you would like us to address, please feel free to email us at HW@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only, and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health, and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.

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